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Care Coordination Specialist
2 months ago
Care Coordination Specialist (RN)
Luminis Health
Part Time - Day shift (M-F, 8a-4:30pm, 24 hrs/week, rotating weekends)
Position Overview:
The Care Coordination Specialist operates under the guidance of the clinical director of care management, facilitating the management of patient care at Luminis Health to ensure safe, efficient, and timely transitions throughout the healthcare continuum. Through a collaborative approach, the specialist will identify, assess, plan, implement, and evaluate the necessary options and services to address an individual's health and related needs, including social determinants impacting overall wellness. The role emphasizes the provision of appropriate resources at the right time and level of care, engaging and supporting patients requiring care management services, and determining the correct initial and ongoing level of care based on evidence-based guidelines.
Key Responsibilities:
1. Identify and prioritize patients requiring care management services using a comprehensive approach that includes biopsychosocial, functional, cultural, spiritual, and financial considerations; employ a multidisciplinary strategy to assess and plan for care needs.
2. Implement strategies such as motivational interviewing to enhance patient engagement, self-management, treatment adherence, and optimal health outcomes.
3. Utilize evidence-based guidelines (such as InterQual or other recognized standards) to ensure quality care, reduce variability, and minimize waste. Confirm appropriate levels of care; document actions to prevent denied days; refer cases to the Physician Advisor as necessary.
4. Actively manage observation stay patients, ensuring timely testing, treatment, and conversion to inpatient status or discharge.
5. Develop and coordinate transition plans for patients moving to home care, community care coordination programs, hospice or palliative care, home infusion, and routine sub-acute and skilled post-acute providers; complete all required documentation and handovers. Prepare patients and families for transitions from various units as indicated.
6. Maintain clear and thorough documentation in each patient record reflecting physical and functional limitations, psychosocial characteristics, educational needs of patients and families, and financial and transition requirements. Initiate referrals to other disciplines as needed.
7. Participate in nursing unit and departmental clinical outcome projects as well as initiatives aimed at improving care management processes.
8. Identify potential or existing patient situations that necessitate referral to other healthcare team members, such as infection control, risk management, or quality management. Ensure that care plans are adjusted as needed and that follow-up occurs, keeping leadership informed of potential issues.
9. Utilize risk and predictive analytic tools, such as readmission risk assessments, applying tailored interventions to address potential barriers or risks, unnecessary prolonged hospitalization, and readmission prevention.
10. Ensure compliance with all regulatory standards (CMS, commercial insurers, etc.).
Qualifications:
BSN or ADN with equivalent experience. A BSN must be obtained within five years of starting in this role.
A minimum of three years of experience in a clinical setting, either ambulatory or post-acute, is required.
Experience in care coordination is preferred.
Licensure/Certification:
Current licensure as a registered nurse by the relevant nursing board.
Compliance with the credentialing requirements as stated in the nursing bylaws.
Working Conditions, Equipment, Physical Demands:
Employees in this position may be exposed to blood-borne pathogens.
Physical Demands - Medium work
The physical demands and work environment described are representative of those encountered while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description provides an overview of the functions and requirements for this position. It is not intended to be an exhaustive list encompassing every duty and requirement; additional duties may be assigned as deemed necessary.
